How to cut suicide rates, healthcare costs, crime, and prices. The gatekeeping problem in 30% of US jobs.
The rules about who is legally allowed to do which jobs are one of the most consequential policy levers most people have never heard of.
When some states allowed psychologists to prescribe antidepressants, the suicide rate dropped 7%.
Psychiatrists are in high demand, so it can take months to see one! Psychologists are also trained to prescribe antidepressants, but often not allowed to.1
Idaho allowed pharmacists to renew insulin prescriptions. Idaho’s ER visits and medical bankruptcies dropped. Usually, renewing required a doctor’s appointment.
When Idaho allowed pharmacists to renew inhalers, fewer families went into medical bankruptcies, and fewer kids went into medical shock.
Montana and Colorado went further. Pharmacists can now diagnose and treat basic ailments like UTIs, pink eye, and cold sores.
These require no new spending or new training. Access to medical care improved by allowing medical professionals to do what they’d already been trained to do.
Occupational licensing is why healthcare is cheaper in some states
Primary care costs roughly a third in Pennsylvania as in many other states, partly because nurse practitioners can see patients for routine visits (e.g., a cold) without a physician present.
Whether nurse practitioners, physician assistants, and pharmacists can do what they’re trained to do depends on state regulations and the strength of medical lobby groups. This is a big deal because there are more nurse practitioners than general practice physicians in the US: 200,600 NPs vs. 153,980 GPs in 2019.
The medical lobby argues that care is worse without a doctor present. That’s technically true. But it ignores the actual alternative: people not seeing anyone if they can’t afford or access a doctor. When more mid-level providers are checking in, more breast and prostate cancers get caught at Stage 1 instead of Stage 3.2
The people who lose out first are rural and low-income. Whether a Minute Clinic can open in your area depends on whether nurse practitioners can pay a supervising doctor $500 to $1,200 a month. If doctors are scarce, this might make clinics impossible in areas with the most need.
This is a problem that democracies will always have to watch out for
These protectionist rules will naturally arise because organized interest groups (businesses or professional associations) lobby for them and set their requirements, often to block competition.
Dentist groups block dental hygienists the same way physician groups use “scope of practice” to limit nurses and pharmacists.
Strict licensing also creates shortages. Foreign-trained physicians must repeat their entire training to practice here. Telehealth providers can’t see patients across state lines, even in rural states with the greatest need.
Legal representation has the same problem. In New York in 2010, 98% of tenants in eviction cases and 95% of parents in child support cases appeared in court without an attorney. To provide legal services, you must have a law degree, pass the bar exam, hold a valid license, and work for a firm “owned, managed, and financed exclusively by lawyers.” This raises the quality of legal services, but means more people go without legal services.
These protections are often not set at a level that helps the public
Professionals often design their own licensing standards, making requirements arbitrarily high.
Until 2024, Louisiana required a floral arrangement exam judged by existing florists, who evaluated their own would-be competitors. The pass rate was 36%, harder than the bar exam.
Nevada requires travel guides to undergo 733 days of training and pay $1,500.
Interest groups use licenses to block competition in unrelated sectors.
In many states, hair braiding is illegal without a 400+ hour cosmetology license covering coloring and chemicals. Natural hair braiding, which has been passed down through generations, is pushed underground, with women of color or immigrant women at risk of being shut down.
Licenses are easy to add and hard to remove.
In Washington State, massaging a horse required a human massage license (hundreds of hours of training for a different skill) plus 100 additional animal-specific hours. To fight the requirement, the Washington Animal Massage Association proposed a new standalone 300-hour animal massage license as an alternative. No one testified against it.
The schools built around licensing requirements fight to keep them.
Cosmetology school tuitions now run $15,000-$20,000, even though median pay is $17 an hour. Nail techs often need 400-600 hours, barbers and cosmetologists often need 1500. Only 10% of those hours are related to safety. For context, an Emergency Medical Technician (EMT) only needs around 120-180 hours.
These dynamics explain why occupational licensing now covers 30% of the U.S. workforce, up from 5% in the 1950s.
Sometimes, licenses are good! After WWII, they helped women prove their qualifications in a workforce that was skeptical of letting them stay. They do raise wages, though often by raising prices or by outlawing competition (like banning nurse-owned clinics).
Well-structured licenses clearly improve safety and quality in two fields: medicine (particularly chiropractic) and the police field. Outside those fields, licensing has little to no effect on quality, or sometimes makes it worse by shielding providers from competition.
These also tend to block women, immigrants, and Black workers from licensed occupations. Sometimes intentionally.
Licensing that excludes people of color, southerners, foreigners, and convicted felons
Massachusetts required a fortune teller license largely to keep Romani people and traveling carnivals away.
Similarly, Texas is considering offering construction tests only in English (no longer Spanish or Vietnamese) and requiring citizenship.
“Moral character” clauses bar people with felony convictions from licenses in half of all states, for any conviction, regardless of relevance or how long ago it occurred.
Sometimes, people are trained and working in a field while incarcerated (e.g., forest firefighting) and then barred from that same work after release.
States with the heaviest burdens of occupational licensing saw a reoffending rate increase of over 9% within three years of release. The states with the lightest burdens saw a 2.5% decrease. Employment after prison is one of the strongest predictors of not reoffending.
Only 21 states allow people with criminal records to ask a licensing board whether their record will disqualify them before they spend time and money on required training. Proving rehabilitation to licensing boards might be impossible.
Southern states have more local-level occupational licensing than the rest of the country. Much of it dates to the Jim Crow era, when it was used to stop formerly enslaved people from moving freely through the South.
The American Medical Association funded a 1910 report that closed 75% of American medical schools, including five of the seven Black medical colleges and most schools that enrolled women and lower-income students. It eliminated the apprenticeship model that offered an affordable path into the nursing field via hospital training.
The new requirements called for two years of basic science followed by two years of clinical training. Schools whose students couldn’t afford four years without income closed.
Its author claimed to support Black medical education. His writings said Black students should treat only Black patients, fill roles subservient to white physicians, and be trained in “hygiene rather than surgery” to protect white Americans from disease.
The closures also hit the schools that had begun admitting women. The few that survived mostly didn’t. The result was the near-elimination of women from the physician workforce between 1910 and 1970.
The downsides are spread out and hard to see
Licensing costs fall on workers who can’t afford it. Low-income women take on thousands of dollars in debt for for-profit cosmetology schools.
Shortages in critical jobs, e.g., nursing. When training costs fall entirely on workers, fewer people can afford to enter the field, no matter how much the job is needed or how well it pays once you get there.
Less surge capacity after disasters. After Hurricane Ian, Florida needed roofers quickly. Workers came from neighboring states. Some were arrested because their licenses didn’t transfer.
People can’t move when they need to. Licensing might have cut interstate mobility by up to 7%. When Arizona announced it would accept any other state’s professional license across all fields, more people moved there, and tax receipts increased.
My co-author Alicia notes that her mother, a P.E. teacher, would have had to redo her schooling after the family moved to South Carolina.
If you move states, you need a new therapist, even if you meet online. When I worked in government and wanted evening therapy appointments, few DC-area therapists had evening slots. I wasn’t allowed to see a California therapist who could have seen me virtually during her afternoon.
Prices increase by around 15% when a service becomes licensed. Daycare costs run 30-50% higher in states with stricter licensing requirements, with no measurable safety gains.
What can change
Almost all occupational licensing happens at the state level (see the full list). The only federally licensed professions are aircraft pilots and maintenance technicians.
At the state level:
Require licenses to be periodically reauthorized with evidence that they protect safety, not just that the licensed industry prefers them. Utah does this.
Reserve full licensing for fields where evidence shows safety gains. For most professions, certifications or apprenticeships work and cost far less.
Encourage paid apprenticeships. In construction, employers can get liability coverage for workers they’re training, creating a paid path in without years of upfront debt or unpaid coursework.
Stop barring people with criminal records from licenses for convictions unrelated to the job.
Expand Universal Licenses. Half of states recognize credentials from other states in some form, but most versions cover few professions, default to the more stringent requirements, and/or require two years of in-state residency before kicking in.3
Federally:
Use federal funding conditions or the interstate commerce clause to push for license portability and felon licensing reform. The federal government cannot directly regulate state licenses.
Create tax incentives for apprenticeships.
This essay was inspired by our last DC Abundance gathering, which featured West Virginia University Knee Regulatory Research Center Director Alicia Plemmons. Sign up here for our next DC Abundance meetup. All errors my own.
Psychiatrists outperform only on bipolar disorder.
Fitzpatrick, Joyce, Mawell Mehlman, Alicia Plemmons, Evelyn Duffy, Joshua Gerlick, Summer Davis, Mark Votruba, and Allison Norful. (2026). `The Role of Full Practice Authority for Nurse Practitioners on Advancing Early Cancer Detection’ ‘American Journal of Preventative Medicine. Forthcoming.
This is from a peer-reviewed paper coming out late Summer. Here is the most recent policy brief: https://csorwvu.com/policy-brief-survey-of-universal-licensing-reforms-in-the-united-states-2024/
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Another area where licensing increase costs is optometry. In all US states, optometrists require a license that needs to be renewed every year or two (depending on the state) and only optometrists can prescribe eyeglasses or contact lenses. And to keep them in business, eyeglasses cannot be purchased without a prescription which expires in one year, even if your vision hasn’t changed. Even a low cost provider like Costco still charges over $100 for an eye exam.
This is all unnecessary. In Japan, optometrists don’t need a license, eyeglasses cannot be purchased without a prescription and most eyeglass stores use fully automated vision testing machines that require no optometrist and only minimal instruction from a clerk. This means you can walk into an eyeglass shop ( which are everywhere ) and walk out with new glasses in an hour for less than just what the optometrists in the US charge for an exam.
Ridiculous that BRAIDING requires a license!
Yes, fix these issues.